Resectable Pancreatic Head Cancer Research Articles

Optimal Management of Resectable Pancreatic Head Cancer in the Elderly Patient: Does Neoadjuvant Therapy Offer a Survival Benefit?

Neoadjuvant therapy (NAT) is a growing strategy for patients with resectable pancreatic ductal adenocarcinoma (PDAC). Elderly patients are at increased risk of treatment withdrawal due to functional decline, and the benefit of NAT in this cohort remains to be studied. The objective of this study was to compare outcomes of elderly patients with resectable head PDAC who underwent NAT or a surgery-first (SF) approach. All patients 75 years of age and older with radiographically resectable (National Comprehensive Cancer Network criteria) PDAC who underwent pancreaticoduodenectomy at a single institution from 2008 to 2017 were analyzed. Baseline characteristics and perioperative outcomes were compared between the SF and NAT cohorts. Recurrence-free survival and overall survival (OS) were analyzed by treatment strategy. Overall, 158 patients were identified: SF cohort=90 (57%) and NAT cohort=68 (43%). Patients in the SF cohort were older (80 vs. 78 years; p=0.01) but there were no differences in preoperative comorbidities or frailty indices. SF patients had a trend toward higher rates of major complications (38% vs. 24%; p=0.06) with higher Comprehensive Complication Index totals (20.9 vs. 20; p=0.03). There were similar rates of adjuvant therapy. NAT was associated with significantly longer OS (24.6 vs. 17.6 months; p=0.01) in both the intent-to-treat and resected cohorts. On multivariable analysis (MVA), NAT remained an independent predictor of OS (hazard ratio 0.60; p=0.02). NAT is safe and effective for elderly patients with PDAC. This study suggests NAT is associated with fewer complications after surgery, equal rates of adjuvant therapy receipt, and increased OS over a surgery-first approach.

Augmented Reality-Assisted Pancreaticoduodenectomy with Superior Mesenteric Vein Resection and Reconstruction.

Introduction Pancreaticoduodenectomy (PD) with superior mesenteric vein (SMV) reconstruction are often required to achieve complete (R0) resection for pancreatic head cancer (PHC) with tumor invasion of the SMV. Augmented reality (AR) technology can be used to assist in determining the extent of SMV involvement by superimposing virtual 3-dimensional (3D) images of the pancreas and regional vasculature on the surgical field. Materials and Methods Three patients with PHC and tumor invasion of the SMV underwent AR-assisted PD with SMV resection and reconstruction following preoperative computed tomography scanning. Preoperative imaging data were used to reconstruct 3D images of anatomical structures, including the tumor, portal vein (PV), SMV, and splenic vein (SV). Using AR software installed on a smart phone, the reconstructed 3D images were superimposed on the surgical field as viewed in a smart phone display to provide intermittent navigational assistance to the surgeon in identifying the boundaries of PHC tumor invasion for resection of the vessels involved. Result All patients successfully completed the operation. Intraoperative AR applications displayed virtual images of the pancreas, SMV, bile duct, common hepatic artery (CHA), and superior mesenteric artery (SMA). Two patients required end-to-end anastomosis for reconstruction of the SMV. One patient required allogenic vascular bypass to reconstruct the SMV-PV juncture with concomitant reconstruction of the SV-SMV confluence by end-to-side anastomosis of the SV and bypass vessel. Postoperative pathology confirmed R0 resections for all patients. Conclusion AR navigation technology based on preoperative CT image data can assist surgeons performing PD with SMV resection and reconstruction.

Clinical impact of preoperative tumour contact with superior mesenteric-portal vein in patients with resectable pancreatic head cancer.

The NCCN classification of resectability in pancreatic head cancer does not consider preoperative radiological tumour ≤ 180° contact with portal vein/superior mesenteric vein (PV/SMV) as a negative prognostic feature. The aim of this study is to evaluate whether this factor is associated with higher rate of incomplete resection and poorer survival. All patients considered for pancreatic resection between 2012 and 2017 at two Spanish referral centres were included. Patients with borderline and locally advanced pancreatic ductal adenocarcinoma (PDAC) according to NCCN classification were excluded. Preoperative CT scans were reviewed by dedicated radiologists to identify radiologic tumour contact with PV/SMV. Out of 302, 71 patients were finally included in this study. Twenty-two (31%) patients showed tumour-PV/SMV contact (group 1) and 49 (69%) did not show any contact (group 2). Patients in group 1 showed a statistically significantly higher rate of R1 and R1-direct margins compared with group 2 (95 vs 28% and 77 vs 10%) and lower median survival (24 vs 41 months, p = 0.02). Preoperative contact with PV/SMV, lymph node metastases, R1-direct margin and NO adjuvant chemotherapy were significantly associated with disease-specific survival at multivariate analysis. Preoperative radiological tumour contact with PV/SMV in patients with NCCN resectable PDAC is associated with high rate of pathologic positive margins following surgery and poorer survival.

Biliary complications during neoadjuvant therapy for pancreatic cancer

Introduction: Neoadjuvant therapy prior to resection of pancreatic head cancer increases time to surgery and thus the possibility of biliary complications. We determined the frequency and impact of biliary complications during neoadjuvant therapy prior to resection. Methods: We completed a retrospective study of patients treated with neoadjuvant therapy for pancreatic head adenocarcinoma from May 2014 through March 2019. Results: Of the 59 patients identified, the average age was 67 and 50.8% were male. Neoadjuvant therapy regimens included gemcitabine and abraxane + chemo-radiation (28 patients, 47.5%), FOLFIRINOX + chemo-radiation (15 patients, 25.4%) and remaining 16 patients received alternative therapeutic combinations based on tolerance. Six (10.1%) patients died prior to completion of neoadjuvant therapy. After completion of all neoadjuvant therapy, 34 (57.6%) patients went on to resection while 19 (32.2%) showed disease progression precluding surgical extirpation. Biliary complications during neoadjuvant therapy affected 16 patients (27%). Biliary interventions included percutaneous cholecystostomy drain (3 patients, 5.1%), ERCP with stent placement or exchange (6 patients, 10.1%), percutaneous transhepatic drain (4 patients, 6.8%) and hospital admission for cholangitis with medical treatment only (2 patients, 3.3%). Eight of the 16 patients with biliary complications went on to surgical resection (50%) compared to 26 of the 43 (60.4%) patients who did not have biliary complications. (χ2=0.18, p = 0.67). Conclusion: Biliary complications during neoadjuvant therapy for pancreatic head cancer are relatively common, but do not significantly affect proceeding to surgical resection.

Allen Whipple. American Knight of surgery (to the 80th anniversary of the first successful one-stage pancreatoduodenal resection)

Abstract. In 1940, having baggage of three fatal two-stage pancreatoduodenal resections, during the demonstration surgery, the famous American surgeon Allen Whipple performs the first successful one-stage pancreatoduodenal resection for pancreatic head cancer. It is immeasurable surprise and respect that such a volume of intervention was not planned, since the patient was diagnosed with a tumor of the antral part of the stomach before the operation. The complexity of the situation didn`t stop Allen Whipples plans, and the subsequent success, which gave not only 9 years of life of the operated patient, but also to the whole world the original method of operation, became the starting point of a new era of pancreatic surgery Whipples contribution to surgery is not limited to performing one-stage pancreatoduodenal resection. He pioneered the reform of postgraduate medical education in the United States of America, founded the worlds first plastic surgery training program, developed new methods of intra- and perioperative management of patients with colon cancer, criteria for diagnosing insulinoma, which are today called the Whipples triad. The study of the structure of the spleen, as well as its role in the spread of tumor cells, made it possible to determine the indications and contraindications for splenectomy. He also developed and applied porto-caval and splenorenal shunting operations, which reduce pressure in the portal vein system in patients with liver cirrhosis.

Hepatic artery reconstruction after extended resection for borderline resectable pancreatic head cancer: A case report

Pancreatic head cancer is frequently associated with invasion of the surrounding vascular structures, such cases being considered for a long period of time as unresectable. Improvement of the vascular surgery techniques allowed association of extended vascular resections and reconstructions, increasing in this way the percentage of patients benefiting from radical surgery. We present the case of a 47-year-old male patient with no significant medical history diagnosed with a large pancreatic head tumor invading the common and proper hepatic artery as well as the portal vein. The venous reconstruction was performed using a synthetic prosthesis while the left hepatic artery was sutured to the left gastric artery; meanwhile the right hepatic artery was reconstructed using the splenic artery. In conclusion, extended hepatic artery resection followed by arterial reconstruction in association with portal vein resection and prosthetic replacement might be needed in cases presenting large pancreatic head tumors with vascular invasion.

Does Pre-operative Biliary Drainage Influence Long-Term Survival in Patients With Obstructive Jaundice With Resectable Pancreatic Head Cancer?

Objectives: Whether pre-operative biliary drainage (PBD) affects long-term survival of patients with obstructive jaundice with pancreatic ductal adenocarcinoma (PDAC) who underwent pancreaticoduodenectomy is still controversial. Most of the previous research did not include the important total serum bilirubin (TB) level before intervention as well as before surgery. The aim of this study is to evaluate the impact of PBD on long-term survival after considering the TB level.Methods: Data were collected retrospectively from patients with obstructive jaundice who underwent resection of pancreatic head cancer in a high-volume center. X-Tile software and Kaplan-Meier survival analysis were applied to determine the optimal cut-off levels for TB and age based on the minimal probability (P)-value and the largest χ2-value. Multivariate Cox regression analyses were performed after univariate analysis to assess independent prognostic factors for overall survival (OS) and disease-free survival (DFS).Results: Of 426 patients with obstructive jaundice who underwent pancreaticoduodenectomy for resectable pancreatic head cancer during a 7 year period, 242 (56.8%) received PBD and 184 (43.2%) underwent surgery directly. The OS of patients who received PBD was significantly worse than that of patients who did not receive PBD by univariate analysis (median of 16.6 vs. 22.2 months, P = 0.048). After including liver function parameters in the multivariate Cox regression, we found that the use of PBD was not associated with OS or DFS, while TB before intervention >150 μmol/L was an independent adverse prognostic factor for both OS [hazard ratio (HR), 1.42; 95% CI, 1.05–1.91] and DFS (HR, 1.38; 95% CI, 1.08–1.77).Conclusions: In patients with obstructive jaundice with resectable pancreatic head cancer, undergoing PBD before pancreaticoduodenectomy did not impair or benefit survival rates compared with surgery alone. However, TB before intervention >150 μmol/L predicted an unfavorable prognosis, irrespective of the PBD procedure.

The Effect of Pancreatoduodenectomy Plus Intraperitoneal Hyperthermic Perfusion on Resectable Pancreatic Head Cancer: Cohort Study.

Intraperitoneal hyperthermic perfusion (IPHP) has achieved positive results in treating various abdominal cancers but infrequently reported in resectable pancreatic head cancer. This study was designed to explore the safety and efficacy of pancreaticoduodenectomy plus intraperitoneal hyperthermic perfusion (PD + IPHP) in patients with pancreatic cancer. Data of pancreatic cancer patients undergoing pancreaticoduodenectomy were retrospectively analyzed, including PD + IPHP (n = 28) and PD group (n=29). IPHP was performed during surgery, on postoperative day (POD) 2, and POD 4 with normal saline as the perfusion solution. Complications and overall survival of these patients were observed and recorded. There was no significant difference in the incidence of major postoperative complications between PD + IPHP group and PD group. The median overall survival (OS) time of the PD + IPHP group was 19.0months, the 1-year survival rate was 82.35%, and the 2-year survival rate was 49.41%. The median OS time of the PD group was 13.0months, the 1-year survival rate was 51.00%, and the 2-year survival rate was 27.33% (Log-rank, P = 0.030; Breslow, P = 0.039). Cox proportional risk model showed that IPHP was an independent factor to improve survival outcomes of these patients (hazard ratio = 0.363, 95% confidence interval: 0.14-0.94; P = 0.038). Intraperitoneal hyperthermic perfusion significantly improves the survival outcomes of pancreatic head cancer patients undergoing PD and does not bring extra risks of complications.

Nationwide practice and outcomes of endoscopic biliary drainage in resectable pancreatic head and periampullary cancer

BackgroundGuidelines advise self-expanding metal stents (SEMS) over plastic stents in preoperative endoscopic biliary drainage (EBD) for malignant extrahepatic biliary obstruction. This study aims to assess nationwide practice and outcomes. MethodsPatients with pancreatic head and periampullary cancer who underwent EBD before pancreatoduodenectomy were included from the Dutch Pancreatic Cancer Audit (2017–2018). Multivariable logistic and linear regression models were performed. ResultsIn total, 575/1056 patients (62.0%) underwent preoperative EBD: 246 SEMS (42.8%) and 329 plastic stents (57.2%). EBD-related complications were comparable between the groups (44/246 (17.9%) vs. 64/329 (19.5%), p = 0.607), including pancreatitis (22/246 (8.9%) vs. 25/329 (7.6%), p = 0.387). EBD-related cholangitis was reduced after SEMS placement (10/246 (4.1%) vs. 32/329 (9.7%), p = 0.043), which was confirmed in multivariable analysis (OR 0.36 95%CI 0.15–0.87, p = 0.023). Major postoperative complications did not differ (58/246 (23.6%) vs. 90/329 (27.4%), p = 0.316), whereas postoperative pancreatic fistula (24/246 (9.8%) vs. 61/329 (18.5%), p = 0.004; OR 0.50 95%CI 0.27–0.94, p = 0.031) and hospital stay (14.0 days vs. 17.4 days, p = 0.005; B 2.86 95%CI −5.16 to −0.57, p = 0.014) were less after SEMS placement. ConclusionThis study found that preoperative EBD frequently involved plastic stents. SEMS seemed associated with lower risks of cholangitis and less postoperative pancreatic fistula, but without an increased pancreatitis risk.

Clinical prognostic factors in patients with resected pancreatic head cancer

Backround: Surgical resection is the best option for patients with pancreatic ductal adenocarcinoma (PDAC) stage I and II. At the time of diagnosis many of apparently resectable tumors are in more advanced stages, and pancreatic cancer must be considered as systematic disease. Determination of pre-operative prognostic factors for 6 months postoperative mortality may improve patients’ selection for surgical resection. Methods: Retrospective review of the Pancreatic Cancer database was performed and patients who underwent radical surgery for adenocarcinoma of the pancreatic head between 2005 and 2015 were included. Khorana score (KS) and inflammatory burden markers- neutrophil-lymphocyte ratio (NLR), lymphocyte- monocyte ratio (LMR), thrombocyte-lymphocyte ratio (PLR) were calculated. The retrieved data was analyzed using SPSS 21.0 A p value <0.05 was concidered significant. The retrospective study was reviewed and approved by Ethics committee. Results: 187 patients were included in the study. Median survival was 13 months, and the 6-month mortality rate 23.4%. Forty-seven patients were classified as high risk according to KS (≥3), with no statistical significance of these patients dying during 6 months following surgery (p=0.158). The postoperative survival was better in LMR>3 group (28±5.1 vs 16.3±2.6 months) and in PLR<150 group (29.1±4.3 vs 25.5±3.9 months), however, no statistically significant difference was found. Patients in NLR<5 group had statistically significant higher rate of survival after pancreatic resection (86.7% vs 13.3%, p=0.05) in a period of six months. We found that NLR>5 (HR: 1.833; 95% Cl: 0.890-3.774, p=0.1) and LMR<3 (HR: 1.316; 95% Cl: 0.535-3.240, p=0.5) might predict early death, however without statistical significance. Conclusions: Marker of inflammatory burden NLR<5 appeared to be useful prognosing increased 6 months survival and longer overall postoperative survival following surgery for PDAC. However, possibly due to insufficient number of patients, we were unable to prove statistical significance in other inflammatory markers and KS.

Neoadjuvant therapy followed by pancreaticoduodenectomy for resectable and borderline resectable pancreatic head cancer: A propensity score matched per protocol analysis

Neoadjuvant therapy followed by pancreaticoduodenectomy for resectable and borderline resectable pancreatic head cancer: A propensity score matched per protocol analysis

Abstract B34: The impact of lymphocyte-to-monocyte ratio (LMR) in patients with borderline resectable pancreatic head cancer after curative surgery

Abstract Introduction: The outcome of patients with borderline resectable pancreatic ductal adenocarcinoma (BR PDAC) remains dismal even if the patients received neoadjuvant chemotherapy followed by radical resection. Pancreatic resection is highly invasive and sometimes fatal; thus, useful preoperative indicators for favorable prognosis of patients with PDAC are needed. Lymphocyte-to-monocyte ratio (LMR) is a systemic inflammatory response marker associated with cancer outcome. In the present study, we evaluated the clinical significance of LMR for BR head-PDAC patients. Materials and Methods: Consecutive 67 borderline resectable (BR) head-PDAC patients who underwent pancreaticoduodenectomy from Jan. 2008 to Dec. 2017 at Chiba University Hospital were analyzed retrospectively. The levels of LMR were calculated by simply dividing the absolute lymphocyte count by the monocyte count from routine preoperative blood sample, and the cut-off value of LMR was determined by receiver operating curve analysis. All the participants were divided into two groups (High/Low) based on the level of LMR. Among the clinicopathologic factors, we analyzed the clinical significance of preoperative LMR using the Kaplan-Meier analysis and Cox proportional regression model. Results: The characteristics of participants were as follows: median age: 67 (interquartile range (IQR) 61-72) years old, sex M/F: 49/18, resectability based on NCCN 2018.2 (BR-PV/BR-A): 38/29, neoadjuvant chemotherapy (done/none): 36/31, adjuvant chemotherapy (done/none): 59/8, R0/1 resection: 51/16, respectively. The median level of preoperative LMR was 4.17 (IQR 2.51-6.09). The cut-off value of LMR was calculated to be 5.63 by applying Youden Index. All PDAC patients were classified into high LMR group (n=20) and low LMR group (n=47). The Kaplan-Meier analysis showed that the outcome of patients in high LMR group was significantly better compared to that in low LMR group (P=0.029 log-rank test). The median overall survival time after surgery was 17.6 months in low LMR group versus 38.1 months in high LMR group. Furthermore, multivariate analysis revealed that high LMR (P=0.012) and low preoperative CA19-9 level (P=0.012) were identified as independent prognostic factors of favorable outcomes in patients with BR head-PDAC. Conclusions: The present study demonstrated both LMR and preoperative CA19-9 were independent prognostic factors in patients with BR head-PDAC. Because these markers can be obtained preoperatively, they will contribute to determination of the strategy for treatment of BR PDAC patients. Citation Format: Yoji Miyahara, Shigetsugu Takano, Hideyuki Yoshitomi, Shingo Kagawa, Katsunori Furukawa, Tsukasa Takayashiki, Satoshi Kuboki, Daisuke Suzuki, Nozomu Sakai, Takashi Mishima, Eri Nakadai, Masayuki Ohtsuka. The impact of lymphocyte-to-monocyte ratio (LMR) in patients with borderline resectable pancreatic head cancer after curative surgery [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer: Advances in Science and Clinical Care; 2019 Sept 6-9; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2019;79(24 Suppl):Abstract nr B34.

Prognostic significance of peritumoral fibrosis after resection of pancreatic head cancer.

Prognostic value of peritumoral fibrosis (PF) in pancreatic head cancer after resection was evaluated. A total of 143 pancreatic cancer patients who underwent tumor resection were enrolled. All patients underwent routine preoperative examination, including contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI). Patients receiving preoperative chemoradiation were excluded because it affects the proportion of fibrosis and cancer cells. Histopathological confirmation and classification of pancreatic head cancer (PHC) was made according to the standards of World Health Organization and the American Joint Committee on Cancer (AJCC). The presence of fibrosis was assessed histologically, and correlated with the clinicopathological characteristics and overall survival using univariate Kaplan-Meier analysis and a stepwise multivariable Cox regression model. Vein resection, resection margin, grading, nodal status, preoperative CA19-9 levels and PF were significantly associated with overall survival. Multivariate analysis showed that all the aforementioned were independent predictive factors of survival. In addition, the survival of patients with PF was significantly worse compared to those without (HR 1.392; P=0.027). Tumor necrosis is a valuable prognostic tool that can be included in the routine post-resection histopathological evaluation of pancreatic head cancer patients.

Invagination of the Adductor Loop of the Small Intestine into the Lumen of the Gastric Stump after Pancreatoduodenal Resection

Aim. To present a rare clinical observation of invagination of the adductor loop of the small intestine into the lumen of the gastric stump after pancreatoduodenal resection. Results. A 69-year-old patient complained of paroxysmal abdominal pain, nausea, vomiting without relief. The patient also reported an episode of black stools 7 years after pancreatoduodenal resection for pancreatic head cancer and 3 years after reconstructive surgery by performing choledochoenteroanastomosis. The invagination of the adductor loop of the small intestine into the lumen of the gastric stump was identified. The mobilization and resection of a fragment of the jejunum with an invagination zone was performed followed by suturing of the distal end of the intestine. Conclusions. Small bowel invagination after abdominal surgery occurs in 1–5% of cases. This case of invagination of the blind end of the adductor loop into the gastric stump through gastroenteroanastomosis caused an acute adductor loop syndrome in the patient. No similar cases have been reported in Russian and foreign publications.

Nakao mesenteric approach in pancreatoduodenectomy for pancreatic head cancer

Abstract The ideal surgery for pancreatic head cancer is isolated pancreatoduodenectomy (PD); that is, en bloc resection using a non-touch isolation technique. We have been developing isolated PD for pancreatic cancer since 1981, when we developed an anti-thrombogenic bypass catheter for the portal vein. In this operation, the first and most important step is the use of a mesenteric approach instead of Kocher's maneuver. The mesenteric approach allows dissection from the non-cancer infiltrating side and determination of cancer-free surgical margins and resectability, followed by systemic lymphadenectomy around the superior mesenteric artery. This approach enables early ligation of the inferior pancreatoduodenal artery and mesopancreas excision. The mesopancreas is the second portion of the pancreatic head nerve plexus. Isolated PD is the ideal surgery for pancreatic head cancer from both surgical and oncological viewpoints. In patients with resectable pancreatic head cancer, isolated PD using the mesenteric approach is suspected to have a higher survival rate than conventional PD using Kocher's maneuver. The precise surgical techniques of the mesenteric approach are herein described.

The diversity between curatively resected pancreatic head and body-tail cancers based on the 8th edition of AJCC staging system: a multicenter cohort study

BackgroundTo our knowledge, there are no studies to systematically compare the detailed clinical significance between curatively resected pancreatic head (ph) and body-tail (pbt) ductal adenocarcinoma based on the new 8th edition of AJCC staging system (8th AJCC stage) that was just applied in clinical practice in 2018.MethodsThree hundred fifty-one patients with curatively resected pancreatic adenocarcinoma (PC) from three center hospitals were entered into this multicenter cohort study.ResultsIncreasing tumor size (P < 0.001), T stage (T1 + T2 vs T3 + T4, P = 0.003), frequent postoperative liver metastasis (PLM) (P = 0.002) and 8th AJCC stage (IA to VI, P < 0.001; I + II vs III + IV, P = 0.002) were closely associated with the progression of pbt cancers compared with that in ph cancer patients. Moreover, tumor size≥3 cm (P = 0.012), 8th AJCC stage (III + IV) (P = 0.025) and PLM (P = 0.010) were identified as independent risk factors in pbt cancers in logistic analysis. Patients with pbt cancers had a significantly worse overall survival compared with ph cancer patients (P = 0.003). Moreover, pbt was an independent unfavorable factor in multivariate analysis (P = 0.011). In addition to lymph nodes metastasis, 8th AJCC stage, vascular invasion and PLM, increasing tumor size and advanced T stage were also closely associated with the poor prognosis in 131 cases of pbt cancer patients compared with Ph cancer patients.ConclusionPbt, as an independent unfavorable factor for the prognosis of PC patients, are much more aggressive than that in ph cancers according to 8th AJCC staging system. 8th AJCC staging system are more comprehensive and sensitive to reflect the malignant biology of pbt cancers.

Preoperative Clinical and Computed Tomography (CT)-Based Nomogram to Predict Oncologic Outcomes in Patients with Pancreatic Head Cancer Resected with Curative Intent: A Retrospective Study.

Background: Currently, proposed nomograms are mainly based on post-operative histopathology. The purpose of this study was to identify preoperative computed tomography (CT) and clinical information that allow prediction of disease-free (DFS) and overall survival (OS) of patients surgically treated for pancreatic head cancer. Methods: A total of 136 patients who underwent curative-intent surgery were retrospectively reviewed. Based on results from multivariate Cox regression analysis, a prediction model was constructed with preoperative CT features and clinical information. Overall performance of the nomogram was calculated by Harrell’s C-index. Results: Symptoms at diagnosis, preoperative serum CA 19-9 ≥ 34 U/mL, and four imaging features (necrosis (DFS, P = 0.066; OS, P = 0.002), possible venous invasion (DFS, P = 0.150, OS, P = 0.055), suspected metastatic regional lymph node (DFS, P = 0.001; OS, P = 0.099), and associated pancreatitis or pseudocyst (DFS, P = 0.013; OS, P = 0.041)) were included to build the nomogram. The c-statistics for the discrimination power of the proposed nomogram was 0.6496 for DFS and 0.6746 for OS. Conclusion: A nomogram derived from preoperative CT and clinical information could estimate the risk of recurrence and all-cause death after curative-intent surgery for radiologically resectable pancreatic head cancer.

How Old is Too Old: Treatment and Survival Disparities in Resectable Pancreatic Head Cancer: An Analysis Using the National Cancer Database

Ivanics, Tommy MD; Leonard-Murali, Shravan MD; Han, Xiaoxia PhD; Steffes, Christopher P. MD, FACS; Shah, Rupen A. MD; Kwon, David S. MD, FACS Author Information

One-Step Surgery in Pancreatic Head Cancer Complicated by Obstructive Jaundice

Objective: to analyze short-term and long-term results of one-step surgery in resectable pancreatic head cancer (PHC), complicated by obstructive jaundice. Material and methods. The retrospective analysis of 123 consecutive cases of the surgical treatment of PHC has been performed. Group I (N = 33) consisted of patients with the total bilirubin level up to 100 µmol/l, group II (N = 31) - with the level of total bilirubin of 100-287 µmol/l who had undergone the one-step surgery. Group III (N = 59) included patients having undergone the surgical treatment with preoperative biliary drainage (PBD) in the form of the biliodigestive anastomoses or external drainage, with the total bilirubin level of 125-720 µmol/l. The frequency of postoperative complications, 90-day lethality and the overall survival rate were assessed by the Kaplan-Meier method. Results. The frequency of complications in the patients of groups I, II and III was 42.4, 48.4 and 35.6 %, lethality - 3.0, 3.2 and 6.8 %, respectively (P &gt; 0.05); the 5-year survival rate - 39.7 ± 8.8 %, 30.1 ± 11.8 % and 4.9 ± 3.1 % (P = 0.004). Conclusion. The one-step surgical treatment of PHC with moderately severe obstructive jaundice was not accompanied with the increased frequency of postoperative complications and mortality. The overall survival rates were significantly higher in the patients undergoing the one-step surgery and did not correlate with the total bilirubin levels. The two-step surgery was accompanied by extremely low survival rates. The cancellation of the routine PBD procedure can be considered as one of the ways to improve the long-term outcomes of the PHC treatment.

Dynamics of the Results of the Treatment of Resectable Pancreatic Head Cancer over a 30-Year Period

Objective: to analyze the dynamics of the immediate and long-term results of the treatment of resectable pancreatic head cancer (PHC) for the period from 1989 to 2019. Material and methods. The retrospective analysis of 123 consecutive cases of the treatment of resectable PHC has been performed. During period I (from 1989 to 2000) 11 patients were operated, during period II (from 2001 to 2013) - 72, and period III (from 2014 to 2019) - 40 patients. The structure and frequency rate of postoperative complications, 90-day mortality and the overall survival rate (by the Kaplan-Meier method) have been assessed. Results. The frequency rate of the postoperative complications in I, II, and III periods were 63.6, 48.6, and 52.5%, mortality - 0, 5,6 and 5.0 %, respectively (P &gt; 0.05). The most common complication and cause of death in all the cases were pancreatic fistula. The indicators of the 3-year survival in I, II, and III periods were 10.0 ± 9.5 %, 18.5 ± 4.7 % and 35.3 ± 9.6 %, the median survival - 10, 13, and 22 months, respectively (P = 0.07). Conclusion . A high frequency rate of the postoperative complications with a relatively low rate of the postoperative mortality was observed in all the analyzed periods. Pancreatic fistula prevailed in the structure of the complications and was the cause of death in all the cases. In the last period there was a clear tendency to improve the long-term results of the treatment, which may be due to more active surgical tactics, increased frequency of combined operations with the resection of vessels and proportional decrease in the share of palliative (R2) operations, standardization of the volume of lymph node dissection, an increased proportion of one-stage operations and increasing the number of patients receiving adjuvant chemotherapy.